What is the treatment approach for a pediatric patient with Food Protein-Induced Enterocolitis Syndrome (FPIES) to chicken?

Treatment of FPIES to Chicken

The cornerstone of FPIES management to chicken is strict dietary elimination of all forms of chicken, combined with acute symptom management based on severity—ranging from oral rehydration at home for mild reactions to aggressive IV fluid resuscitation and ondansetron for moderate-to-severe episodes. 1

Long-Term Management: Dietary Elimination

Complete avoidance of chicken in all forms is the primary treatment strategy. 1

• Eliminate chicken from the diet entirely, including all processed foods containing chicken protein 1
• Educate caregivers and all care providers (daycare, schools, family members) on strict avoidance strategies 1
• Strongly consider nutritional consultation regardless of the number of food triggers to ensure adequate nutrition and adherence to dietary restrictions 1
• Children with 3 or more FPIES triggers are at increased risk for poor weight gain and food aversion, requiring closer nutritional monitoring 2
• Develop an individualized complementary feeding plan to support normal growth and development while avoiding allergens 2

Acute Episode Management

Treatment of acute FPIES reactions to chicken depends on severity and should follow a structured algorithmic approach:

Mild Reactions (1-2 episodes of emesis, no lethargy)

• Attempt oral rehydration with breast-feeding or clear fluids 1
• If age ≥6 months: consider ondansetron intramuscular 0.15 mg/kg/dose (maximum 16 mg) 1, 3
• Monitor for resolution approximately 4-6 hours from onset 1
• Mild-to-moderate reactions can often be managed at home with oral rehydration 1

Important caveat: Ondansetron should NOT be administered to children <6 months of age 3, 4. Exercise special caution in children with underlying heart disease due to QT interval prolongation risk 1, 4, 5.

Moderate Reactions (>3 episodes of emesis with mild lethargy)

• If age ≥6 months: administer ondansetron intramuscular 0.15 mg/kg/dose (maximum 16 mg) 1, 5
• Consider placing peripheral IV line for normal saline bolus 20 mL/kg, repeat as needed 1
• Transfer to emergency department or intensive care unit if persistent or severe hypotension, shock, extreme lethargy, or respiratory distress develops 1

Severe Reactions (>3 episodes of emesis with severe lethargy, hypotonia, ashen/cyanotic appearance)

Priority is restoration of stable hemodynamics through aggressive fluid resuscitation: 1

• Place peripheral IV line immediately and administer normal saline bolus 20 mL/kg rapidly; repeat as needed to correct hypotension 1
• If age ≥6 months: administer IV ondansetron 0.15 mg/kg/dose (maximum 16 mg) 1, 5
• If IV access is delayed and age ≥6 months: give ondansetron intramuscular 0.15 mg/kg/dose (maximum 16 mg) 1, 5
• Consider IV methylprednisolone 1 mg/kg (maximum 60-80 mg/dose) to decrease presumed cell-mediated inflammation, though no studies support this recommendation 1
• Administer dextrose saline as continuous IV maintenance infusion 1
• Monitor and correct acid-base and electrolyte abnormalities 1
• Correct methemoglobinemia if present with methylene blue 1
• Monitor vital signs continuously 1
• May require supplemental oxygen, mechanical ventilation, or vasopressors for severe cases 1
• Discharge after 4-6 hours from onset when patient returns to baseline and tolerates oral fluids 1

Critical Management Pitfalls

Epinephrine autoinjectors are NOT routinely recommended for FPIES 1. The exception is patients with concomitant IgE-mediated food allergy who are at risk for anaphylaxis—these patients should be prescribed epinephrine at physician's discretion 1.

Screen for cardiac history before ondansetron administration, including congenital heart disease or arrhythmias, as ondansetron can prolong the QT interval 4, 5.

Monitoring for Resolution

• Plan for periodic re-evaluations with supervised oral food challenges to monitor for resolution 6
• Perform food challenges in children with history of severe FPIES in a hospital or monitored setting with immediate IV resuscitation availability 1
• Chicken is a recognized FPIES trigger beyond the typical cow's milk and soy, with reactions developing within 2 hours of ingestion 7
• Be aware that atypical FPIES with positive specific IgE can shift to IgE-mediated reactions, requiring adaptation of challenge protocols 8

Emergency Action Planning

Develop a written emergency treatment plan that includes:

• Recognition of symptoms (repetitive vomiting 1-4 hours after chicken ingestion, potential progression to lethargy and shock) 6
• Home management instructions for mild reactions 1
• Clear criteria for seeking emergency care 1
• Medication dosing based on current weight 5